Negotiating Risk Ethically

1. Negotiating Risk Ethically Coast Mental Health Ethics Committee Presentation May 2011

2. Latest trends in Risk Management • Individual expectations : clients as consumers vs. patients; client rights, client-driven treatment • Professional: obligation to respect, community-based treatments, client-centered approaches, safety at workplace • Political / systemic: democratic freedoms, multiculturalism, de-institutionalization, shorter hospital stays, bed shortage • Societal: liberal values, autonomy and choice, community integration, tendency to litigious claims

3. Who defines the risk? How the risk is defined?

4. Living at Risk • Living at risk results from client’s autonomous but imprudent decisions that have potential for negative outcomes.

5. Living at Risk Dilemma Most ethical dilemmas related to living at risk are related to the conflict over obligation to honor client autonomy vs. obligation to provide care / benefit the client (beneficence vs. non-maleficence) and by assuming paternalistic position to avoid / minimize harm to the client / others. (based on Haddad, 1992)

6. Risk Defined • At self – self harm, suicide, reckless activities / lifestyle, refusal of or non compliance with treatment / medications, substance use, self-neglect • At others – threats, physical violence, property damage, • By others – physical / sexual / emotional abuse, abuse of power, neglect, financial indiscretions, discrimination, bullying

7. Formulating Ethical Question re Risk / Living at Risk • Given uncertainty of outcomes or conflict about values, what decisions or actions related to living at risk are ethically justifiable? OR • Given uncertainty of outcomes or conflict about values, is it ethically justifiable to allow clients live at risk?

8. Four Quadrant Approach to Ethics Questions in Healthcare I. clinical / health indications II. client preferences III. quality of life IV. contextual features of the case.

9. Elements of ethical analysis Problem – ethical question Information gathering (four quadrant approach) Options and their ethical grounding Preferred choice / decision Ethical rationale for the preferred choice(s) / decision Recommendations Plan of action Evaluation / Lessons learned?

10. Three Levels of Moral Reasoning re Risk Management LEVEL I: CASUISTRY • Looking at present case of risk / potential risk in the context of past cases and find out how they were negotiated / resolved previously

11. Three Levels of Moral Reasoning re Risk Management cont. LEVEL II: RULES AND RIGHTS • apply principles of bioethics: autonomy of a person to live at risk; professional obligation to benefit / provide care and support and avoid harm / protect others; justice / non-discriminatory approach to risk management • set specific codes: professional standards of competencies and practice • establish specific rules: obtaining informed consent • reinforce rights & responsibilities of clients and professionals • balance and consider rule challenges: respect for autonomy rule vs. what if the autonomy would do more harm and break the beneficence / do not harm rules?

12. Three Levels of Moral Reasoning re Risk Management cont. LEVEL III: NORMATIVE ETHICS(establishing theoretical norms to justify rules and claims) • Value consideration: what things related to living at risk / taking risks / negotiating risk do clients (also professionals, society) intrinsically value? • Virtue consideration: what are the traits of a good mental health provider who negotiates risk ethically?

13. Central Issues related to Risk Management • Prediction of risk and consequences • Duty to intervene • Duty to protect • Accountability and rights of a person

14. Decision re risk – client factors: refusal to comply vs. informed consent • Competency / decisional capability • Voluntariness / lack of undue influence • Knowledge / access to information

15. Risk Measurement - Factors • Likelihood: rare, unlikely, possible, likely, almost certain • Severity: insignificant, minor, moderate, major, extreme • The degree: slight, tolerable, moderate, substantial, critical / intolerable (reversible vs. irreversible) • Urgency for preventive action: slight, tolerable, moderate, substantial, critical

16. Duty to intervene Slight Tolerable Moderate Explain Negotiate Persuade Substantial Critical Pressure Physically coerce

17. Risk Management Rules • RULE #1: Risk management interventions are never based on convenience or gratification. • RULE #2: Negotiating risk ethically involves the minimal use of power to attain maximum benefit and minimum infringement on client’s liberty. • RULE #3: • The more grave consequences - the greater obligation to intervene.

18. In case of Conflict If the client is capable – the client should be considered a decision-maker (respect for autonomy). If the client is not capable, then family / advocate / substitute decision maker / health care professionals may make decisions. Decisions are made using: • Substituted judgment – what the client would have chosen if capable • Best interest – what a reasonable person in that situation would have chosen If the intervention is ineffectual (futile), too costly, and/or harmful to client or others, or it compromises professional integrity – the intervention may not be offered / client preference not honored (justifiable withdrawal)

19. MH practitioners’ obligations related to risk management • Professional: therapeutic alliance, duty to serve • Ethical / moral: beneficence, non-maleficence, respect for autonomy, justice, veracity, fidelity • Legal: protection from harm, safety regulations

20. Factors in Risk Management related to setting Acute setting Community setting Client-centered Less structured / home-like environment Clients more stable Long term relationships • Professional / policy centered • Structured environment • Client more sick / vulnerable • Short term relationships

21. Approaches to negotiating risk Protective factors Client: strengths, abilities, insight, decision making / problem solving, coping skills; Supports: information, supervision / attention, time, accommodation, respect, permission to make mistakes, tolerance, non-judgment, inclusion, flexibility, creativity, client-focused care; Administrative: safety agreement, service agreement, standards of practice(i.e. informed consent), safety protocols, staff training, multidisciplinary approach.

22. Approaches to negotiating risk Dignity of risk (balance of risk): • tolerable vs. intolerable • moderate vs. extreme • reversible vs. irreversible

23. Negotiating Risk Ethically Paternalistic approach further stigmatizes mentally ill people and inadvertently denies them equal human and moral standing; therefore, may be considered unjust and hurtful.

24. References • Browne, A. (2006). Community Care Toolkit for Ethical and Clinical decision making for Complex and High Risk Clients. Author • Browne, A. & Sweeney, V. (1995). A short guide to clinical ethics. Vancouver • Provincial health Ethics network www.phen.ab.ca • Vancouver Coastal Health (2004). Vancouver community health services / community mental health services ethical decision making framework and process. Vancouver: VCH • Weiss Roberts, L & Dyer, A. R. ((2003). Concise guide to ethics in mental health care. Washington, DC: American Psychiatric Publishing.

25. Coast Mental Health Ethics Committee To contact Coast Ethics Committee: e-mail: beataz@coastmentalhealth.com or e-mail ethicscorner@coastmentalhealth.com or call: 604-512-3735 Thank you for your attention!